Joint aspiration

The anterior cruciate ligament (ACL)
Joint aspiration

Joint aspiration

Synovial fluid analysis is a series of tests performed on synovial (joint) fluid to help diagnose and treat joint-related abnormalities. To obtain a synovial fluid sample, a needle is inserted into the knee between the joint space. When the needle is in place the synovial fluid is then withdrawn. The sample is sent to the lab for analysis.

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Arthrography

Medical- Medicine

What are the benefits vs. risks?

Benefits

  • Arthrography is particularly effective for detecting tears or lesions of the structures and ligaments of the joints, especially the knee, wrist and elbow, as well as rotator cuff tears or damage from a shoulder dislocation.

Exams involving x-ray imaging:

  • No radiation remains in a patient’s body after an x-ray examination.
  • X-rays usually have no side effects in the diagnostic range.

Exams involving MR imaging:

  • MRI is a noninvasive imaging technique that does not involve exposure to ionizing radiation.
  • MRI enables the discovery of abnormalities that might be obscured by bone with other imaging methods.
  • The contrast material used in MRI exams is less likely to produce an allergic reaction than the iodine-based contrast materials used for conventional x-rays and CT scanning.

Risks

  • Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.

Exams involving x-ray imaging:

  • There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk.
  • Patients who have known allergies to iodine may have an adverse reaction to the contrast material. Because the contrast material is put in a joint and not a vein, allergic reactions are very rare, although in some cases, mild nausea to severe cardiovascular complications may result.
  • Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. See the Safety page for more information about pregnancy and x-rays.
  • The effective radiation dose for this procedure varies. See the Safety page for more information about radiation dose.

Exams involving MR imaging:

  • The MRI examination poses almost no risk to the average patient when appropriate safety guidelines are followed.
  • If sedation is used there are risks of excessive sedation. The technologist or nurse monitors your vital signs to minimize this risk.
  • Although the strong magnetic field is not harmful in itself, implanted medical devices that contain metal may malfunction or cause problems during an MRI exam.
  • There is a very slight risk of an allergic reaction if contrast material is injected. Such reactions usually are mild and easily controlled by medication. If you experience allergic symptoms, a radiologist or other physician will be available for immediate assistance.
  • Nephrogenic systemic fibrosis is currently a recognized, but rare, complication of MRI believed to be caused by the injection of high doses of gadolinium contrast material in patients with very poor kidney function.

A Word About Minimizing Radiation Exposure

Special care is taken during x-ray examinations to use the lowest radiation dose possible while producing the best images for evaluation. National and international radiology protection councils continually review and update the technique standards used by radiology professionals.

State-of-the-art x-ray systems have tightly controlled x-ray beams with significant filtration and dose control methods to minimize stray or scatter radiation. This ensures that those parts of a patient’s body not being imaged receive minimal radiation exposure.

Arthrography

Medical- Medicine

Who interprets the results and how do I get them?

A radiologist, a physician specifically trained to supervise and interpret radiology examinations, will analyze the images and send a signed report to your primary care or referring physician, who will discuss the results with you.

Follow-up examinations are often necessary, and your doctor will explain the exact reason why another exam is requested. Sometimes a follow-up exam is done because a suspicious or questionable finding needs clarification with additional views or a special imaging technique. A follow-up examination may be necessary so that any change in a known abnormality can be detected over time. Follow-up examinations are sometimes the best way to see if treatment is working or if an abnormality is stable over time.

Arthrography

Medical- Medicine

How is the procedure performed?

Iodine contrast material has been injected into the shoulder joint - this is a shoulder arthrogram.

Iodine contrast material has been injected into the shoulder joint - this is a shoulder arthrogram.

This examination is usually done on an outpatient basis.

The patient is positioned on the examination table and x-rays are taken of the joint to be compared later with the arthrograms. If recent x-rays are available, the physician may choose to use these for reference.

Next, the skin around the joint is cleansed with antiseptic and a local anesthetic is injected into the area.

Your physician will numb the area with a local anesthetic.

The area where the needle is to be inserted will be sterilized and covered with a surgical drape.

A needle is then inserted into the joint. The radiologist, a physician specifically trained to supervise and interpret radiology examinations, will use a syringe to drain the joint fluid, which may be sent to a laboratory for analysis. Aspiration is typically performed when an infection is suspected.

The contrast material and sometimes air are injected into the joint space and the needle is removed. Air will not be used if the patient is undergoing MR arthrography. The patient will be asked to move the affected joint to distribute the contrast material throughout the space.

The conventional arthrography exam is usually completed within 30 minutes. Exams involving MRI may take more than one hour.

Third Party Extensions

Google Maps API Tutorial

Using EInsert.groundOverlay

EInsert.groundOverlay() is a static method which creates an EInsert() object using parameters similar to those of GGroundOverlay(). I.e. it uses a GLatLngBounds to specify the corners of the region, instead of using a centre point and size.

Here’s an example

In order to use EInsert.groundoverlay() you need to:

  1. Create a suitable image. Transparent PNG format is particularly suitable. Animated GIF format is not suitable.
  2. Include a copy of the “einsert.js” file. Please take your own local copy, don’t hot link to my copy of the file.
  3. Create some EInsert objects using EInsert.groundoverlay().
  4. Use map.addOverlay() to add them to the map.

Create some EInsert objects using EInsert.groundoverlay()

E.g.

      var insert = EInsert.groundOverlay("foo.png",new GLatLngBounds(sw,ne));

The parameters are:

  1. A string containing the URL of the image.
  2. A GLatLngBounds() specifying the bounds of the region.
  3. (Optional) zindex and pane control value.
    Use -1 if you want this EInsert to be placed below any polylines and GTileLayerOverlay()s.
    use 0 if you want this EInsert to be placed above any polylines and below any GTileLayerOverlay()s.
    Use 1 if you want this EInsert to be placed above any polylines and GTileLayerOverlay()s.
    Use other values to place one EInsert above or below another.
  4. (Optional) GProjection to be used for non-mercator map
  5. (Optional) Zoom level to be used for calculations if the GProjection doesn’t have a zoom level 17.

For normal maps that use the Mercator projection, omit the last two parameters.
The number of zoom levels in a GProjection is not exposed, so if you are using a custom GProjection with fewer zoom levels, you need to tell me the highest zoom level that I can use for the calculations.

Note Don’t write “new EInsert.groundOverlay(…)”. EInsert.groundOverlay() is a static method, not a constructor.

The EInsert() created by EInsert.groundOverlay() supports all the usual EInsert() methods. See Using the EInsert extension

More advanced stuff

Google Maps API Tutorial

Altitude

Google themselves don’t serve altitude information, so if you want to obtain the altitude, you’ll need to get it from somewhere else.

Here’s a simple example

One place where you can get altitude information is the US Geological Survey Elevation Query. Information about their service can be found here:
gisdata.usgs.gov/XMLWebServices/TNM_Elevation_Service.php

A request looks like this:
http://gisdata.usgs.gov/xmlwebservices2/elevation_service.asmx/getElevation?X_Value=-118.4&Y_Value=36.7&Elevation_Units=METERS&Source_Layer=-1&Elevation_Only=true.

The parameters are:

X_Value Longitude
Y_Value Latitude
Elevation_Units METERS or FEET.
Source_layer You can use this to request data from a specific survey, or use -1 to request the best available data at the location.
Elevation_Only true or false. If you set it false you get information about the data source as well as the elevation data.

The service provides a SOAP interface that returns XML, so you can’t access it directly from Javascript for security reasons. What you have to do is to write a little server script that runs in your own domain. Your Javascript can send a request to your own server, which then sends the request to USGS and returns the reply back to your Javascript client.

I’m not a PHP expert, but I managed to throw together something that works for this purpose. A general purpose relay script would need to be more complicated than this, to avoid the possibility of cross-domain attacks, but I think I can trust the USGS. My PHP code looks like this and returns the data like this:altitude.php?lat=53&lng=-2.

There are two asynchronous steps in this chain, so don’t expect to be able to write a function that returns the altitude of a point. Send the request with GDownloadUrl() and then process the reply in the callback funtion. If you’re sending several requests (e.g. to obtain the profile of a cycle route) you can wrap your call in a function and use it to hold Function Closure so that you can match the replies back to the requests.

The service will return up to 10 decimal places of information, but I suspect that the surveys aren’t accurate to 0.1 nanometres. In my code I just use the integer value.

The service returns the value 0 for open sea. You could therefore use it to distinguish land from sea, but there are a few other points on land where the elevation is also zero, e.g. Elburg in the Netherlands.

The documentation states that the service can return the value -1.79769313486231E+308 if there is no valid data for the requested location, so you might want to filter out such values if you’re drawing an elevation diagram.

In this example I use GDirections to find a route, use the EPoly extension to obtain points at equal distances along that route, use USGS to find the altitude at those points, and use the Google Chart API to plot a chart of those altitudes.

More advanced stuff

Google Maps API Tutorial

GLayers

API v2.130 introduces GLayers, which can be used for displaying the Wikipedia and Panoramio layers to your map.

Google themselves don’t (yet) supply a control for allowing users to switch layers on and off, so I wrote this example

IDs and LMCs

The documented way to specify a particular layer is by using its ID. The official list of IDs is atspreadsheets.google.com/pub?key=p9pdwsai2hDN-cAocTLhnag

In addition to the official list, there are also “com.panoramio.popular”, which omits the Panoramio elements that have the small icons, and there’s “com.youtube.all” which displays the YouTube layer, and there are a few other Wikipedia languages. I don’t intend to test all possible Wikipedia languages: If your favourite language is supported by Wikipedia but isn’t in the official GLayers list, try it anyway.

There’s also an undocumented way to specify a particular layer, by using its LMC. E.g.map.addOverlay(new GLayer(“lmc:panoramio/0”)) is the same as map.addOverlay(new GLayer(“com.panoramio.popular”)).

You can only use IDs that the particular release of the main API code knows about, because the main API code needs to know how to translate the ID into an LMC. In v2.130, the known IDs are “com.panoramio.all”, “com.panoramio.popular” and “org.wikipedia.*”.

When you use an LMC, the main API code doesn’t need to translate it for you, so you can use any LMC for which there is a service.

At the moment, the only LMC that I know about that has service but no ID is “lmc:panoramio/1”, which displays the unpopular Panoramio entries and omits the popular ones.

Viewing the source of maps.google.com reveals the existence of “lmc:youtube”, but the API has no service for it at the moment.

hide() and show()

GLayers support .hide(), .show() and .isHidden().

GLayers don’t support .supportsHide().

More advanced stuff

Google Maps API Tutorial

Context Menus for Overlays

Although there is an undocumented “singlerightclick” event for markers and some other overlays, it’s safer to use the documented map “singlerightclick” event because undocumented features could be changed or removed in future API releases without notice.

When using the map “singlerightclick” event to handle overlays we need to examine the third argument that gets returned. This argument indicates the overlay on which the click occurred.

You might want to display different options depending on the type of overlay that was clicked. You can test the type of overlay like if (overlay instanceof GMarker) {…}

At present, if a right click occurs on an infowindow, no “singlerightclick” event is generated.

Any variables that are going to be needed by the menu functions need to be held in global variables, because clicks on the menu are executed in global context. In particular, that means that we need to store a global reference to the overlay on which we opened the menu.

More advanced stuff

Google Maps API Tutorial

Arrows

It’s possible to put arrowheads onto polylines by using the Google direction marker triangle icons.

The direction markers have names like “dir_0.png”, “dir_3.png”, up to “dir_117.png”. The numbers indicate the direction in degrees. Only integers that are a multiple of 3 are supported. Only values below 120 degrees are supported, but since the marker has threefold symmetry, it looks the same if rotated back by 120 degrees.

Here’s an example

In the upper polyline of that example, I calculate the bearing between the last two points in the array that’s used to create the polyline, and place the arrowhead, pointing in that direction, over the last point of the polyline.

In the lower polyline of that example, I calulate the bearing between the previous point and the next point to determine a tangent direction.

More advanced stuff

Google Maps API Tutorial

Limiting the range

If you want to limit the range of zoom levels that the user is allowed to use on your map, you can overwrite the .getMinimumResolution() and .getMaximumResolution() methods of all the map types.

If you want to limit the range of movement that the user is allowed to use on your map, you can add listeners for the “move” event, and countermand any operations that go outside the permitted region.

Things happen so quickly that there’s no time for anything out of bounds to get plotted, so it all looks reasonably smooth.

Here’s an example

What I’ve done for the position is to specify an allowable region in GLatLngBounds() format, and require that the centre point lie within that region.

Potential Pitfalls

  1. Make sure that your permitted region is larger than the visible region at the maximum permitted zoom level.
  2. Allow enough room around the edge so that the automatic movements caused by opening infowindows partially off screen are not restricted.
  3. Don’t call map.setCenter() unless you are actually changing the values. E.g. if you omit the “if” statement around “map.centerAtLatLng(new GPoint(X,Y));”, then that operation itself would trigger a “move” event, and the code would go into a loop.
  4. Don’t try to use the .lat.hi. .lat.lo, .lng.hi and .lng.lo properties of the GLatLngBounds() object.
    The values are in radians, not degrees, so they can’t be used for recentering the view.

The Basics

Google Maps API Tutorial

Google Earth Icons

The Google Earth icons are now available on the Google Maps server (so that Google Maps can render KML files that use them). There are four folders of icons

Each of the folders contains 64 icons (some of which are duplicates) named icon0.png to icon64.png

For each icon there’s a main icon image PNG (32 x 32) and a shadow image PNG (59 x 32) in the same folder.
No suitable transparent images, print images or imageMaps seem to be available.

 icon27.png  icon27s.png

These settings are suitable for most of the Google Earth icons:

   Icon.iconSize=new GSize(32,32);
   Icon.shadowSize=new GSize(56,32);
   Icon.iconAnchor=new GPoint(16,32);
   Icon.infoWindowAnchor=new GPoint(16,0);

Here’s an example

Pal2

icon0.png icon1.png icon2.png icon3.png icon4.png icon5.png icon6.png icon7.png
icon8.png icon9.png icon10.png icon11.png icon12.png icon13.png icon14.png icon15.png
icon16.png icon17.png icon18.png icon19.png icon20.png icon21.png icon22.png icon23.png
icon24.png icon25.png icon26.png icon27.png icon28.png icon29.png icon30.png icon31.png
icon32.png icon33.png icon34.png icon35.png icon36.png icon37.png icon38.png icon39.png
icon40.png icon41.png icon42.png icon43.png icon44.png icon45.png icon46.png icon47.png
icon48.png icon49.png icon50.png icon51.png icon52.png icon53.png icon54.png icon55.png
icon56.png icon57.png icon58.png icon59.png icon60.png icon61.png icon62.png icon63.png

Pal3

icon0.png icon1.png icon2.png icon3.png icon4.png icon5.png icon6.png icon7.png
icon8.png icon9.png icon10.png icon11.png icon12.png icon13.png icon14.png icon15.png
icon16.png icon17.png icon18.png icon19.png icon20.png icon21.png icon22.png icon23.png
icon24.png icon25.png icon26.png icon27.png icon28.png icon29.png icon30.png icon31.png
icon32.png icon33.png icon34.png icon35.png icon36.png icon37.png icon38.png icon39.png
icon40.png icon41.png icon42.png icon43.png icon44.png icon45.png icon46.png icon47.png
icon48.png icon49.png icon50.png icon51.png icon52.png icon53.png icon54.png icon55.png
icon56.png icon57.png icon58.png icon59.png icon60.png icon61.png icon62.png icon63.png

Pal4

icon0.png icon1.png icon2.png icon3.png icon4.png icon5.png icon6.png icon7.png
icon8.png icon9.png icon10.png icon11.png icon12.png icon13.png icon14.png icon15.png
icon16.png icon17.png icon18.png icon19.png icon20.png icon21.png icon22.png icon23.png
icon24.png icon25.png icon26.png icon27.png icon28.png icon29.png icon30.png icon31.png
icon32.png icon33.png icon34.png icon35.png icon36.png icon37.png icon38.png icon39.png
icon40.png icon41.png icon42.png icon43.png icon44.png icon45.png icon46.png icon47.png
icon48.png icon49.png icon50.png icon51.png icon52.png icon53.png icon54.png icon55.png
icon56.png icon57.png icon58.png icon59.png icon60.png icon61.png icon62.png icon63.png

Pal5

icon0.png icon1.png icon2.png icon3.png icon4.png icon5.png icon6.png icon7.png
icon8.png icon9.png icon10.png icon11.png icon12.png icon13.png icon14.png icon15.png
icon16.png icon17.png icon18.png icon19.png icon20.png icon21.png icon22.png icon23.png
icon24.png icon25.png icon26.png icon27.png icon28.png icon29.png icon30.png icon31.png
icon32.png icon33.png icon34.png icon35.png icon36.png icon37.png icon38.png icon39.png
icon40.png icon41.png icon42.png icon43.png icon44.png icon45.png icon46.png icon47.png
icon48.png icon49.png icon50.png icon51.png icon52.png icon53.png icon54.png icon55.png
icon56.png icon57.png icon58.png icon59.png icon60.png icon61.png icon62.png icon63.png

The Basics

Google Maps API Tutorial

Using GOverviewMapControl

GOverviewMapControl provides an “overview” map which is linked to the main map.

Here’s an example

Tweaking the Overview map

In versions below v2.93 the following tweaks can be applied directly.
In version v2.93 and above you need to wait for the control code to be loaded from an external module.
See Tweaking GOverviewMapControl in v2.93

Absolute Positioning

Positioning the overview can be achieved by obtaining a reference to the div that contains the overview map and applying styles to it. The “id” of the overview div is created from the “id” of the parent map by appending “_overview”. So if your main map is called “map”, the overview map div will be called “map_overview”.

Applying styles

Once you’ve got a reference to the div, you could apply other styles to it. Those margins on the left and top look rather odd when it’s not in the corner of the page. I guess that the styles might be likely to change in future releases, so the styles that I apply in the example may well need to be changed.

The overview has three nested divs, the outer one has id=”map_overview”. The API styles are:

  • Outer div: width and height set to the requested GSize() or (150,150).
  • Next div: width and height set to the requested GSize() or (150,150), background-color: white, border-top and border-left: “1px solid gray”.
  • Inner div: width and height 9px less than the outer div size, background-color: “rgb(229, 227, 223)”, border: “1px solid gray”, left: “7px”, top: “7px”.

It’s the “left:7px; right:7px” that causes the map to be placed asymmetrically within the div.

In my example, I make the border go all the way round, centre the inner div within the middle div, and change the size of the inner div to be an even number of pixels so that the margins are the same width all the way round.

Accessing the overview GMap2

It is possible to get a reference to the GMap2 that sits inside the GOverviewMapControl, and then use GMap2 methods to manipulate it.

Here’s an example that changes the map type of the overview and sets up a “click” listener on it.

Restrictions

  • Many GMap2 methods can’t be used on the overview until the GOverviewMapControl has completed its initialisation. If you try to perform them in the same “time slice” as the GOverviewMapControl was created, you’ll get an error. The calls can be deferred, like thissetTimeout("ovmap.setMapType(G_SATELLITE_MAP);",1);.
  • There’s no point using setCenter() or setZoom() on the overview, since the GOverviewMapControl code will update those settings the next time the main map information changes.

Heart attack recovery

Heart Disease

Psychological issues

Depression affects one in four people after a heart attack. It’s critical to address any depression – it won’t just go away on its own and it can make it harder for you to make any necessary lifestyle changes or follow your doctor’s advice on particular treatments. Without specific help, those who become depressed don’t recover as well as they might.

If you take part in a cardiac rehabilitation programme, it will be able to offer treatments ranging from medication to group therapy and stress management (stress and anger may contribute to a heart attack by producing changes in your body that increase your risk of blood clots).

Clinical Trials

Heart Disease

The National Heart, Lung, and Blood Institute (NHLBI) is strongly committed to supporting research aimed at preventing and treating heart, lung, and blood diseases and conditions and sleep disorders.

NHLBI-supported research has led to many advances in medical knowledge and care. For example, this research has helped explore methods and devices for treating heart problems.

The NHLBI continues to support research on various heart treatments, including pacemakers. For example, a current study is exploring the benefits of temporary biventricular pacemakers for patients who have had cardiopulmonary bypass surgery.

Much of the NHLBI’s research depends on the willingness of volunteers to take part in clinical trials. Clinical trials test new ways to prevent, diagnose, or treat various diseases and conditions.

For example, new treatments for a disease or condition (such as medicines, medical devices, surgeries, or procedures) are tested in volunteers who have the illness. Testing shows whether a treatment is safe and effective in humans before it is made available for widespread use.

By taking part in a clinical trial, you might gain access to new treatments before they’re widely available. You also will have the support of a team of health care providers, who will likely monitor your health closely. Even if you don’t directly benefit from the results of a clinical trial, the information gathered can help others and add to scientific knowledge.

If you volunteer for a clinical trial, the research will be explained to you in detail. You’ll learn about treatments and tests you may receive, and the benefits and risks they may pose. You’ll also be given a chance to ask questions about the research. This process is called informed consent.

If you agree to take part in the trial, you’ll be asked to sign an informed consent form. This form is not a contract. You have the right to withdraw from a study at any time, for any reason. Also, you have the right to learn about new risks or findings that emerge during the trial.

For more information about clinical trials related to pacemakers, talk with your doctor. You also can visit the following Web sites to learn more about clinical research and to search for clinical trials:

http://clinicalresearch.nih.gov
http://www.clinicaltrials.gov
http://www.nhlbi.nih.gov/studies/index.htm
http://www.researchmatch.org
For more information about clinical trials for children, visit the NHLBI’s Children and Clinical Studies Web page.

Methods of pacing

Heart Disease
Three leads can be seen in this example of a cardiac resynchronization device: a right atrial lead (solid black arrow), a right ventricular lead (dashed black arrow), and a coronary sinus lead (red arrow). The coronary sinus lead wraps around the outside of the left ventricle, enabling pacing of the left ventricle. Note that the right ventricular lead in this case has 2 thickened aspects that represent conduction coils and that the generator is larger than typical pacemaker generators, demonstrating that this device is both a pacemaker and a cardioverter-defibrillator, capable of delivering electrical shocks for dangerously fast abnormal ventricular rhythms.

Three leads can be seen in this example of a cardiac resynchronization device: a right atrial lead (solid black arrow), a right ventricular lead (dashed black arrow), and a coronary sinus lead (red arrow). The coronary sinus lead wraps around the outside of the left ventricle, enabling pacing of the left ventricle. Note that the right ventricular lead in this case has 2 thickened aspects that represent conduction coils and that the generator is larger than typical pacemaker generators, demonstrating that this device is both a pacemaker and a cardioverter-defibrillator, capable of delivering electrical shocks for dangerously fast abnormal ventricular rhythms.

Biventricular pacing (BVP)
A biventricular pacemaker, also known as CRT (cardiac resynchronization therapy) is a type of pacemaker that can pace both the septal and lateral walls of the left ventricle. By pacing both sides of the left ventricle, the pacemaker can resynchronize a heart whose opposing walls do not contract in synchrony, which occurs in approximately 25-50 % of heart failure patients. CRT devices have at least two leads, one in the right ventricle to stimulate the septum, and another inserted through the coronary sinus to pace the lateral wall of the left ventricle. Often, for patients in normal sinus rhythm, there is also a lead in the right atrium to facilitate synchrony with the atrial contraction. Thus, timing between the atrial and ventricular contractions, as well as between the septal and lateral walls of the left ventricle can be adjusted to achieve optimal cardiac function. CRT devices have been shown to reduce mortality and improve quality of life in patients with heart failure symptoms; a LV ejection fraction less than or equal to 35% and QRS duration on EKG of 120 msec or greater.CRT can be combined with an implantable cardioverter-defibrillator (ICD).

X-ray image of installed pacemaker showing wire routing

X-ray image of installed pacemaker showing wire routing

Advancements in function
A major step forward in pacemaker function has been to attempt to mimic nature by utilizing various inputs to produce a rate-responsive pacemaker using parameters such as the QT interval, pO2 – pCO2 (dissolved oxygen or carbon dioxide levels) in the arterial-venous system, physical activity as determined by an accelerometer, body temperature, ATP levels, adrenaline, etc. Instead of producing a static, predetermined heart rate, or intermittent control, such a pacemaker, a ‘Dynamic Pacemaker’, could compensate for both actual respiratory loading and potentially anticipated respiratory loading. The first dynamic pacemaker was invented by Dr. Anthony Rickards of the National Health Hospital, London, UK, in 1982.[citation needed]
Dynamic pacemaking technology could also be applied to future artificial hearts. Advances in transitional tissue welding would support this and other artificial organ/joint/tissue replacement efforts. Stem cells may or may not be of interest to transitional tissue welding.
Many advancements have been made to improve the control of the pacemaker once implanted. Many of these have been made possible by the transition to microprocessor controlled pacemakers. Pacemakers that control not only the ventricles but the atria as well have become common. Pacemakers that control both the atria and ventricles are called dual-chamber pacemakers. Although these dual-chamber models are usually more expensive, timing the contractions of the atria to precede that of the ventricles improves the pumping efficiency of the heart and can be useful in congestive heart failure.
Rate responsive pacing allows the device to sense the physical activity of the patient and respond appropriately by increasing or decreasing the base pacing rate via rate response algorithms.
The DAVID trials[25] have shown that unnecessary pacing of the right ventricle can exacerbate heart failure and increases the incidence of atrial fibrillation. The newer dual chamber devices can keep the amount of right ventricle pacing to a minimum and thus prevent worsening of the heart disease.

History

Heart Disease
The first implantable pacemaker

The first implantable pacemaker

n 1899, J A McWilliam reported in the British Medical Journal of his experiments in which application of an electrical impulse to the human heart in asystole caused a ventricular contraction and that a heart rhythm of 60-70 beats per minute could be evoked by impulses applied at spacings equal to 60-70/minute.
In 1926, Dr Mark C Lidwell of the Royal Prince Alfred Hospital of Sydney, supported by physicist Edgar H Booth of the University of Sydney, devised a portable apparatus which “plugged into a lighting point” and in which “One pole was applied to a skin pad soaked in strong salt solution” while the other pole “consisted of a needle insulated except at its point, and was plunged into the appropriate cardiac chamber”. “The pacemaker rate was variable from about 80 to 120 pulses per minute, and likewise the voltage variable from 1.5 to 120 volts” In 1928, the apparatus was used to revive a stillborn infant at Crown Street Women’s Hospital, Sydney whose heart continued “to beat on its own accord”, “at the end of 10 minutes” of stimulation.
In 1932, American physiologist Albert Hyman, working independently, described an electro-mechanical instrument of his own, powered by a spring-wound hand-cranked motor. Hyman himself referred to his invention as an “artificial pacemaker”, the term continuing in use to this day.
An apparent hiatus in publication of research conducted between the early 1930s and World War II may be attributed to the public perception of interfering with nature by ‘reviving the dead’. For example, “Hyman did not publish data on the use of his pacemaker in humans because of adverse publicity, both among his fellow physicians, and due to newspaper reporting at the time. Lidwell may have been aware of this and did not proceed with his experiments in humans”.
An external pacemaker was designed and built by the Canadian electrical engineer John Hopps in 1950 based upon observations by cardio-thoracic surgeon Wilfred Gordon Bigelow at Toronto General Hospital . A substantial external device using vacuum tube technology to provide transcutaneous pacing, it was somewhat crude and painful to the patient in use and, being powered from an AC wall socket, carried a potential hazard of electrocution of the patient by inducing ventricular fibrillation.

In 1958, Arne Larsson (1915-2001) became the first to receive an implantable pacemaker. He had a total of 26 devices during his life and campaigned for other patients needing pacemakers.

In 1958, Arne Larsson (1915-2001) became the first to receive an implantable pacemaker. He had a total of 26 devices during his life and campaigned for other patients needing pacemakers.

A number of innovators, including Paul Zoll, made smaller but still bulky transcutaneous pacing devices in the following years using a large rechargeable battery as the power supply.
In 1957, Dr. William L. Weirich published the results of research performed at the University of Minnesota. These studies demonstrated the restoration of heart rate, cardiac output and mean aortic pressures in animal subjects with complete heart block through the use of a myocardial electrode. This effective control of postsurgical heart block proved to be a significant contribution to decreasing mortality of open heart surgery in this time period.
In 1958 Colombian electrical engineer Jorge Reynolds Pombo constructed an external pacemaker, similar to those of Hopps and Zoll, weighing 45 kg and powered by a 12 volt auto battery, but connected to electrodes attached to the heart. This apparatus was successfully used to sustain a 70 year old priest, Gerardo Florez.
The development of the silicon transistor and its first commercial availability in 1956 was the pivotal event which led to rapid development of practical cardiac pacemaking.
In 1958, engineer Earl Bakken of Minneapolis, Minnesota, produced the first wearable external pacemaker for a patient of Dr. C. Walton Lillehei. This transistorised pacemaker, housed in a small plastic box, had controls to permit adjustment of pacing heart rate and output voltage and was connected to electrode leads which passed through the skin of the patient to terminate in electrodes attached to the surface of the myocardium of the heart.
The first clinical implantation into a human of a fully implantable pacemaker was in 1958 at the Karolinska Institute in Solna, Sweden, using a pacemaker designed by Rune Elmqvist and surgeon Åke Senning, connected to electrodes attached to the myocardium of the heart by thoracotomy. The device failed after three hours. A second device was then implanted which lasted for two days. The world’s first implantable pacemaker patient, Arne Larsson, went on to receive 26 different pacemakers during his lifetime. He died in 2001, at the age of 86, outliving the inventor as well as the surgeon.
In 1959, temporary transvenous pacing was first demonstrated by Furman et al. in which the catheter electrode was inserted via the patient’s basilic vein.
In February 1960, an improved version of the Swedish Elmqvist design was implanted in Montevideo, Uruguay in the Casmu Hospital by Doctors Fiandra and Rubio. That device lasted until the patient died of other ailments, 9 months later. The early Swedish-designed devices used rechargeable batteries, which were charged by an induction coil from the outside.
Implantable pacemakers constructed by engineer Wilson Greatbatch entered use in humans from April 1960 following extensive animal testing. The Greatbatch innovation varied from the earlier Swedish devices in using primary cells (mercury battery) as the energy source. The first patient lived for a further 18 months.
The first use of transvenous pacing in conjunction with an implanted pacemaker was by Parsonnet in the USA, Lagergren in Sweden and Jean-Jaques Welti in France in 1962-63. The transvenous, or pervenous, procedure involved incision of a vein into which was inserted the catheter electrode lead under fluoroscopic guidance, until it was lodged within the trabeculae of the right ventricle. This method was to become the method of choice by the mid-1960s.

World's first Lithium-iodide cell powered pacemaker. Cardiac Pacemakers Inc. 1972

World's first Lithium-iodide cell powered pacemaker. Cardiac Pacemakers Inc. 1972

The preceding implantable devices all suffered from the unreliability and short lifetime of the available primary cell technology which was mainly that of the mercury battery.
In the late 1960s, several companies, including ARCO in the USA, developed isotope powered pacemakers, but this development was overtaken by the development in 1971 of the lithium-iodide cell by Wilson Greatbatch. Lithium-iodide or lithium anode cells became the standard for future pacemaker designs.
A further impediment to reliability of the early devices was the diffusion of water vapour from the body fluids through the epoxy resin encapsulation affecting the electronic circuitry. This phenomenon was overcome by encasing the pacemaker generator in an hermetically sealed metal case, initially by Telectronics of Australia in 1969 followed by Cardiac Pacemakers Inc of Minneapolis in 1972. This technology, using titanium as the encasing metal, became the standard by the mid-1970s.
Others who contributed significantly to the technological development of the pacemaker in the pioneering years were Bob Anderson of Medtronic Minneapolis, J.G (Geoffrey) Davies of St George’s Hospital London, Barouh Berkovits and Sheldon Thaler of American Optical, Geoffrey Wickham of Telectronics Australia, Walter Keller of Cordis Corp. of Miami, Hans Thornander who joined previously mentioned Rune Elmquist of Elema-Schonander in Sweden, Janwillem van den Berg of Holland and Anthony Adducci of Cardiac Pacemakers Inc.Guidant.

Stem Cell Treatment Might Reverse Heart Attack Damage

Heart Disease

MONDAY, Feb. 13 (HealthDay News) — Stem cell therapy’s promise for healing damaged tissues may have gotten a bit closer to reality. In a small, early study, heart damage was reversed in heart-attack patients treated with their own cardiac stem cells, researchers report.

The cells, called cardiosphere-derived stem cells, regrew damaged heart muscle and reversed scarring one year later, the authors say.

Up until now, heart specialists’ best tool to help minimize damage following a heart attack has been to surgically clear blocked arteries.

“In our treatment, we dissolved scar and replaced it with living heart muscle. Such ‘therapeutic regeneration’ has long been the holy grail of cell therapy, but had never been accomplished before; we now seem to have done it,” said study author Dr. Eduardo Marban, director of the Cedars-Sinai Heart Institute in Los Angeles.

However, outside experts cautioned that the findings are preliminary and the treatment is far from ready for widespread use among heart-attack survivors.

The study, published online Feb. 14 in The Lancet, involved 25 middle-aged patients (average age 53) who had suffered a heart attack. Seventeen underwent stem cell infusions while eight received standard post-heart attack care, including medication and exercise therapy.

The stem cells were obtained using a minimally invasive procedure, according to the researchers from Cedars-Sinai and the Johns Hopkins Hospital in Baltimore.

Patients received a local anesthetic and then a catheter was threaded through a neck vein down to the heart, where a tiny portion of muscle was taken. The sample provided all the researchers needed to generate a supply of new stem cells — 12 million to 25 million — that were then transplanted back into the heart-attack patient during a second minimally invasive procedure.

One year after the procedure, the infusion patients’ cardiac scar sizes had shrunk by about half. Scar size was reduced from 24 percent to 12 percent of the heart, the team said. In contrast, the patients receiving standard care experienced no scar shrinkage.

Initial muscle damage and healed tissue were measured using MRI scans.

After six months, four patients in the stem-cell group experienced serious adverse events compared with only one patient in the control group. At one year, two more stem-cell patients had a serious complication. However, only one such event — a heart attack — might have been related to the treatment, according to the study.

In a news release, Marban said that “the effects are substantial and surprisingly larger in humans than they were in animal tests.”

Other experts were cautiously optimistic. Cardiac expert Dr. Bernard Gersh, a professor of medicine at Mayo Clinic, is not affiliated with the research but is familiar with the findings.

“This study demonstrates that it is safe and feasible to administer these cardiac-derived stem cells and the results are interesting and encouraging,” he said.

Another specialist said that while provocative and promising, the findings remain early, phase-one research. “It’s a proof-of-concept study,” said interventional cardiologist Dr. Thomas Povsic, an assistant professor of medicine at the Duke Clinical Research Institute, in Durham, N.C.

And Dr. Chip Lavie, medical director of Cardiac Rehabilitation and Prevention at the John Ochsner Heart and Vascular Institute, in New Orleans, also discussed the results. He said that while the study showed that the cardiac stem cells reduced scar tissue and increased the area of live heart tissue in heart attack patients with moderately damaged overall heart tissue, it did not demonstrate a reduction in heart size or any improvement in the heart’s pumping ability.

“It did not improve the ejection fraction, which is a very important measurement used to define the overall heart’s pumping ability,” Lavie noted. “Certainly, much larger studies of various types of heart attack patients will be needed before this even comes close to being a viable potential therapy for the large number of heart attack initial survivors.”

Povsic concurred that much larger studies are needed. “The next step is showing it really helps patients in some kind of meaningful way, by either preventing death, healing them or making them feel better.”

It’s unclear what the cost will be, Povsic added. “What society is going to be willing to pay for this is going to be based on how much good it ends up doing. If they truly regenerate a heart and prevent a heart transplant, that would save a lot money.”

Marban, who invented the stem cell treatment, said the while it would not replace bypass surgery or angioplasty, “it might be useful in treating ‘irreversible’ injury that may persist after those procedures.”

As a rough estimate, he said that if larger, phase 2 trials were successful, the treatment might be available to the general public by about 2016.

Dr. R.K. Tongia – Profile

Heart Disease

Name: Dr. R.K. Tongia
Designation:

HOD & Senior Consultant

Brief Description:

Dr. R.K.Tongia is Head of the Department – Cardiology. Dr. Tongia is M.B.B.S. & M.D. (Medicine &Therapeutics) from S.M.S.Medical College Jaipur, ECFMG Certification from Educational Comm for Foreign Medical Graduates Philadelphia, USA; M.R.C.P. Royal College of Physicians of Ireland, Dublin. He has 30 years of rich experience. He has been awarded FRCP by Royal College of Physicians of Edinburgh, UK; FRCPI by Royal College of Physicians of Ireland, Dublin; FACC by American College of Cardiology, USA.
Areas of Expertise:

Cardiology

Location:

Jaipur

MORE DETAILS

Languages spoken
    English, Hindi
Previous experience Prior to joining FEHJ, Mr. Tongia was sharing his expertise as Consultant Cardiologist and Executive Director for Tongia Heart and General Hospital Jaipur.
Professional Memberships
  • Medical Practitioners Society, Jaipur
  • Society of Nuclear Medicine of India
  • Indian Federation of Ultrasound in Medicine & Biology
  • International Medical Sciences Academy
  • Pediatrics Cardiac Society of India
  • Private Hospital & Nursing Homes Society, Jaipur.
Education and fellowships
  • ECFMG Certification from Educational Comm for Foreign Medical Graduates Philadelphia, USA;
  • M.R.C.P. Royal College of Physicians of Ireland, Dublin
  • M.B.B.S. & M.D. (Medicine &Therapeutics) from S.M.S. Medical College Jaipur,
Specialty Interests
    Regular community initiative programs like Public Lectures, Free Medical Camps, Heart Hospital CPR Training Program.
Awards & Honors He has been awarded FRCP by Royal College of Physicians of Edinburgh, UK; FRCPI by Royal College of Physicians of Ireland, Dublin; FACC by American College of Cardiology, USA.

Centre for Cardiac Sciences

Heart Disease

DR. JAMSHED J DALAL is a rare triple Doctorate, having a Doctorate in Medicine, a Doctorate in Cardiology from Mumbai and a PhD from UK

Specialist in coronary angiography and angioplasty. He did his first coronary angiography in UK in 1978 and since then has done more than 15000 cases over 30 years. He also began the angiography program, available in only four hospitals in Mumbai in 1984 along with a handful of cardiologists.

Involved in the coronary angioplasty program since the invention of angioplasty procedure and is involved in teaching the procedure to doctors in India and China over the last 20 years.

As the Chief Cardiologist at the Holy Family Hospital in Bandra, set up the ICCU unit at the hospital.

In 1987 as the Honarary Cardiologist at the newly constructed Hinduja Hospital, Dr. Dalal set up the Cardiac Catheterization Lab at the hospital and started the coronary angiography and angioplasty procedures. Headed the department for 8 years to establish it as a leading centre in India .

In 1995 also joined the still under construction Lilavati Hospital and helped along with others to set up the hospital along with the department of cardiology. Since inception to leaving the hospital in 2009 remained the coordinator of the Cardiovascular Division and guided the Specialty to international levels.

In 1999, helped along with two other colleagues to setup and establish the Wockhardt Heart Hospital at Mulund, Mumbai. Once again creating a world class cardiology facility in the eastern suburbs.

In 2008 he has now joined the Kokilaben Dhirubhai Hospital as the Director – Centre for Cardiac Sciences. He has already fully established the coronary and peripheral vascular and surgical program, and is in the process of starting the paediatric cardiology and electrophysiology specialities.

Teenage health campaigns ‘reduce adult heart risks

Heart Disease

Health campaigns targeted at teens could help reduce their risk of heart problems as adults, a study suggests.

Smoking can have a big impact on general health and cholesterol levels in later life

Smoking can have a big impact on general health and cholesterol levels in later life

Concerns have been raised that warning signs like high cholesterol are being seen in the young, laying the foundation for future health problems.

But the study of more than 500 people found those with high cholesterol at 15 could normalise it by their mid-30s.

The Australian research is published in Archives of Pediatrics and Adolescent Medicine.

Participants in the Australian study had levels of cholesterol and other blood fats measured in 1985 when they were aged 9, 12 or 15.

They were measured again between 2004 and 2006, an average of 20 years later.

High risk levels in this study were defined as a total cholesterol level of 240 miligrams per deciliter or higher (6.2mmol/l).

The average total cholesterol level in the UK is 5.5mmol/l for men and 5.6mmol/l for women.

Height, weight, waist circumference, skin-fold thickness, smoking habits and cardio-respiratory fitness were also measured in the study.

Good and bad

Of those participants who had high-risk cholesterol levels in their youth, those who stopped smoking or lost weight became low-risk in adulthood, while those who increased their body weight or who started smoking were more likely to maintain those high-risk levels 20 years later.

Costan Magnussen, lead study author from the University of Tasmania, said their findings were important.

“They suggest that beneficial changes in modifiable risk factors in the time between youth and adulthood have the potential to shift those with high-risk blood lipid and lipoprotein levels in youth to low-risk levels in adulthood,” he said.

He added that prevention programmes targeted at the young could also benefit those who develop bad habits as they get older.

Dr John Coleman, chairman of the Association for Young People’s Health, said: “This reseach gives a very clear example of why we need to invest more in adolescent health and make it a higher priority.

“It is clear that young people’s lifestyle choices have a long term impact on their health and it is cost effective and sensible to work with them to encourage healthy habits.”

Mike Knaptonof the Brtish Heart Foundation said: “All teenagers can do something to improve their cholesterol.

“We should all be eating five portions of fruit and veg a day. And, most importantly, the message is don’t smoke.”